New Clinical Quality Measures (CQM) Manual Released!

An updated Medisoft Clinical/LytecMD/Practice Partner Clinical Quality Measures (CQM) User’s Manual has been released!

The manual includes changes to configuration requirements for some of the measures as well as details on where the reports pull information from in order to calculate the denominators and numerators. CQM Report User’s Guide Nov 2014

Who should review the new CQM manual?

  • Providers that are participating in the EHR Incentive Program in 2014 who will be attesting under Stage 1 2014 Objectives
  • Providers who will be reporting Stage 2 Objectives in 2014
  • All providers that are participating in the EHR Incentive Program in 2015 (Remember unless 2015 is your first year to participate the 2015 reporting period is currently scheduled as a full calendar year. This means providers need to be ready to capture CQM data starting January 1, 2015)

As a reminder, providers attesting Stage 1 2014 Objectives, or Stage 2 for 2014 and in 2015 will be required to report a total of 9 measures covering at least 2 of the National Quality Strategy domains. Under 2014 rules providers are no longer required to report a core set of measures, however CMS has outlined a recommended set of 9 Adult Measures, and 9 Pediatric Measures. For detailed information please visit the EHR Incentive Website: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2014_ClinicalQualityMeasures.html

No Threshold Requirement for CQM Reporting

For providers that are unable to find 9 out of the available measures in their CEHRT that apply to their specialty, CMS has stated: “We understand cases may exist where an EP may not find a full set of CQMs where they have data for both the numerator and denominator. We remind providers that they may submit a zero as the denominator for a CQM if that is the resulting calculation displayed by their EHR” https://www.federalregister.gov/articles/2014/09/04/2014-21021/medicare-and-medicaid-programs-modifications-to-the-medicare-and-medicaid-electronic-health-record

CQM Reporting in 2014 using the Flexibility Rule

Under the new Flexibility Rule providers may be eligible for the following options for 2014 Reporting:

CEHRT Options 2014

According to the Final Rule, Providers must attest to the required set of objectives and measures applicable for the CEHRT option they choose, as well as the CQMs that relate to that option.

CQM Reporting Options Flexibility Rule

If a provider chooses the 2013 Stage 1 objectives and measures they must attest to the CQMs using the reporting requirements specified for 2013. (6 total measures comprising of 3 core/alternate core, and 3 additional measures) The reports for 2013 CQMs are only available if the provider is running Medisoft Clinical/LytecMD/Practice Partner v9.5.2.

CQM Comparison

According to the final rule, “If a provider elects to use a combination of 2011 Edition and 2014 Edition CEHRT and chooses to attest to the 2013 Stage 1 objectives and measures for its EHR reporting period in 2014, the provider would be required to report CQMs by attestation using the same measure sets and reporting criteria outlined earlier for providers who elect to use only 2011 Edition CEHRT for the EHR reporting period in 2014. Because of the differences in how CQMs are calculated and tested between the 2011 and the 2014 Editions of CEHRT, we further proposed that a provider may attest to data for the CQMs derived exclusively from the 2011 Edition CEHRT for the portion of the reporting period in which 2011 Edition CEHRT was in place.”

Since the 2013 CQM Reports are only available in Medisoft Clinical/LytecMD/Practice Partner v9.5.2 providers are reminded that they should run the CQM report PRIOR to upgrading with a date range equal to the first day of the reporting period up to the date of the upgrade. Providers are advised to maintain copies of the report as supporting documentation for their attestation. Once the upgrade to v11 has been completed the practice will not have access to run the 2013 CQM report again.

EHR Incentive Program CQM Reporting Options for Eligible Professionals in 2014 Include:

    • Option 1: Attest to CQMs through the EHR Registration & Attestation System (Reporting Period: 90 day period for first time participants, all others must select any 3 month quarter.)
    • Option 2: eReport CQMs through Physician Quality Reporting System (PQRS) Portal (Reporting Period: Entire calendar year)

Because the 2014 CEHRT versions of Medisoft Clinical/LytecMD/Practice Partner (v11) were not released until after the start of the year, and due to the fact that many of the measures require configuration or changes to documentation in order to capture the data in a manner that will produce numbers on the CQM reports, it is unlikely that any providers will have a full year’s worth of data in their CQM reports. In addition v11 is not currently compatible with PQRS direct EHR reporting requirements. Therefore, participants of the EHR Incentive program should report their numbers for their 3-Month quarter/reporting period in 2014 through attestation. We further recommend reporting PQRS data through a qualified registry. For more information on PQRS registry reporting visit: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_Registry_Made_Simple_F01-08-2014.pdf

For assistance with configuration or training please contact us to schedule some one-on-one time with a Certified Trainer!

Disclaimer: AZCOMP Technologies, Inc, (AZCOMP) is providing this material as an informational reference for eligible professionals. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of posting, the CMS programs are constantly changing, and it is the responsibility of each provider to remain abreast of the CMS program requirements.